In oncology, cancer centers and hospital networks are finding both utility and value in the development of disease-specific, evidence-based treatment algorithms, sometimes known as clinical care pathways, to help standardize diagnosis, treatment, and management for the most common disease presentations.1 Pathways can be shared across care teams to ensure payer-mandated care management and best practices are visible to the team at all times. Such service line standardization helps providers improve both the quality of care and the patient experience.
Pathways and Care Coordination
Clinical pathways are a critical structural element in the effort to reduce variability in health care and to make costs and outcomes more measurable, predictable, and accountable.2 As value-based reimbursement models become more common, reliable care coordination and clinical pathways are essential to reducing the cost and variability of oncology care and improving outcomes.
Many pathways, such as those developed by the National Institute for Health and Care Excellence (NICE), the National Comprehensive Cancer Network (NCCN) and other groups, are already accepted by providers to support decision-making. Recently, a host of oncology clinical pathway pilot programs (eg, BlueCross Blue Shield of Michigan, OPR) have reported improved clinical and financial outcomes. These results affirm that cancer care cost savings and reductions in cancer-related emergency room visits and inpatient admissions can be achieved with provider participation in payer-supported oncology pathways programs. Further, they demonstrate cost savings of up to 15% on aggregated breast cancer, colon cancer, and lung cancer spending can be achieved in the first year of a pathways program concurrent, with as much as a 7% reduction in hospital admissions.2
Barriers to Pathway Development and Standardization
With increased focus on controlling costs and improving treatment outcomes, care pathways are gaining traction in many service lines. However, the process of pathway development is fraught with barriers, including the cost to develop or purchase the pathways and the investment of time, expertise, and leadership focus. Developing pathways requires collaboration and consensus from the many stakeholders.3
Another significant challenge is the necessary organizational shift in thinking. Clinicians may resist standardization as “cookie cutter” medicine; management may be reluctant to disrupt established workflows; regional payers may be skeptical that changes in imaging utilization will ultimately reduce costs.
The need to retro-fit electronic health records (EHRs) to accommodate new clinical pathways is another significant and time consuming barrier.
Steps to Create Locally Designed Consensus-driven Pathways
Instilling an institution-wide culture of evidence-based care, supported by standardized diagnostic pathways, is a complex undertaking. The specific approaches must be tailored to meet the needs of an individual system and its many stakeholders, though a comprehensive approach typically includes:
- Project definition and situational analysis Discussions between a small group of key clinical and administrative personnel and a medical affairs consulting team experienced in imaging-specific quality improvement programs are the first step. The goal is to define the scope and goals of the project.
- Stakeholder consensus and support Bringing together all stakeholders (ie, oncologists and referring physicians, imaging-center clinicians, cancer center management, representatives from regional payers) is necessary to build consensus for the new approach. The goal is a clear understanding of current utilization patterns and costs, definitions of core concepts, goals, and benefits; and agreement on expected limitations.
- Disease-specific pathway design Once stakeholder support has been established, a multidisciplinary clinical team should select and prioritize key disease indications for clinical pathway design. From this larger group, smaller working groups can create disease-specific diagnostic pathways. With consultant facilitation, the working group performs a baseline assessment of current practice, including scan volumes by tumor type, stage, and referrer; quality of images and reports; and the potential referring community and regional imaging market. A review of the relevant clinical literature and national treatment guidelines in the context of the community culture is another important step.
- Pathway integration into medical automation systems and administrative workflows Oncology care management systems and medical automation systems must be evaluated to determine whether patients proceeding through specific regimens of diagnosis, treatment, and monitoring can be scheduled at the correct time for the most appropriate diagnostic tests. Simultaneously, new administrative workflows can be designed to streamline and expedite referral intake, pre-authorizations, scheduling, coding, claim submissions, and reimbursement.
Pathways in the Age of Navigation and Coordination
Patient navigation programs are a meaningful addition to the quality of care. Advances in care coordination and navigation software provide an opportunity for pathways to be integrated into technology platforms — making pathways easily referenceable by navigators and care coordinators from diagnosis through survivorship. The power of navigation and access to pathways in a care coordination setting was demonstrated at the University of Alabama at Birmingham (UAB). Seeking to improve patient engagement, UAB designed a program to help patients overcome transportation issues, scheduling challenges, and other barriers to care. Approximately 30% of UAB’s Medicare patients were paired with a lay navigator. When researchers compared utilization before and after implementation, they saw:
- 18% decrease in hospitalizations
- 12% decrease in emergency department visits
- 14% decrease in intensive care unit admissions
Most striking, over the first 5 quarters of the program, costs decreased by approximately $952 per beneficiary — amounting to an estimated total reduction of more than $18 million for patients receiving navigation.4 It is important to note that these results were achieved without a fully integrated care coordination platform, where pathways can be integrated for decision support or to track advanced patient engagement measures.
Future Challenges in Pathway Development
Addressing comorbidities Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients with comorbidity are less likely to receive treatment with curative intent.5 Competent software must address this key determinant in quality of care. One-third of patients with cancer in the United States who are older 65 have at least 1 comorbidity; those with lung or colorectal cancer typically have more than 1, according to new government figures. “For cancer patients, incorporating comorbidity measures into treatment planning may lead to better decisions about the potential risks and benefits of treatment options,” said the latest Annual Report to the Nation on the Status of Cancer.6
Beyond distress assessment: active symptom management Oncology clinicians understand patients with advanced cancer rarely present with just 1 symptom. Poly-symptomatic patients frequently experience symptoms such as depression, anxiety, fatigue, pain, poor appetite, and dyspnea.7 Early detection and remediation of critical symptoms improves the care experience, improves clinical outcomes, and conserves cost. Early intervention at less expensive, clinically appropriate settings can impact emergency department and hospital admissions. Digital tools to interact with patients and actively monitor symptoms are essential to the next generation of care coordination software.
Triggers for palliative care referrals Patients who received palliative care along with standard treatment for advanced cancer reported having a better quality of life and mood than patients who did not receive early palliative care, according to the results of a randomized clinical trial. Patients who received early palliative care also scored better on assessments of ability to cope with their disease and were more likely to discuss end-of-life care preferences with their health care team.8 Emerging software should have automatic triggers for palliative assessments based on clinical risk factors, stage of disease, co-morbidities, functional status, and age.
Combining standardized pathways informed by evidence-based knowledge with advances in care coordination platforms represents the next wave in care management. This linking will allow doctors to standardize care paths to quickly identify and manage at-risk patients, empower care teams to implement and track care plans, engage patients in care management, and provide improved communication with patients and their families.
Dr Bridwell is chief medical officer, Appian 360. He is a subject matter expert in advanced diagnostic imaging, with a specialization in oncology algorithm development. He is board certified in both internal medicine and nuclear medicine and completed his Nuclear Medicine Fellowship at Walter Reed Army Medical Center in Bethesda, Maryland. He has held academic appointments at the Uniformed Services University of Health Sciences and the University of Texas, San Antonio. He has developed or co-developed educational and technology products that include PETLinQ™, a referring physicians guide on when to use PET CT, and RISLinQ™, a fully integrated radiology information system.
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4. Saulet D. The financial toxicity of cancer: the side effects we have to start treating. Advisory Board Blog. June 24, 2014.
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6. American Cancer Society. Cancer Facts & Figures 2017. Atlanta, GA: American Cancer Society; 2017.
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8. NCI Staff. Study confirms benefits of early palliative care for advanced cancer. National Cancer Institute website. www.cancer.gov/news-events/cancer-currents-blog/2016/palliative-care-quality. Published October 5, 2016. Accessed June 7, 2016.